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Lebanon: Integrating Mental Health into Primary Health Care

April 11, 2011

Written by
Gary Zeitounalian

International Medical Corps began operating in Lebanon during war in the summer of 2006 and played an integral role in providing relief to conflict-affected populations. The organization remained in Lebanon following the August ceasefire to assist in reconstruction efforts and implement a diverse set of development initiatives, ranging from primary health care (PHC) and mental health activities to education, livelihoods development, gender-based violence response and water/sanitation programs. In 2008, International Medical Corps began integrating mental health into PHC programs in order to promote a community-based mental health system that aims to benefit all individuals.

To the general public in Lebanon, mental health and the need to seek treatment from a mental health specialist are hampered by stigma and misconceptions. Most view mental health disorders as stemming from “the evil eye,” curses, bad luck, or stress. Like most Mediterranean cultures, the Lebanese usually express their emotional concerns through somatic or physical complaints, because they are more socially acceptable. As a result, mental health issues are often displayed and described as being symptoms like a stomach ache, body pains, or a migraine. Therefore, affected individuals are more likely to visit their family doctor to seek treatment for their mental health issues. The family doctor or general practitioner (GP), being unaware of the true cause of the individual’s complaints, might prescribe medication, while the patient’s underlying mental health needs are left unaddressed. As GPs are often the first line of treatment, International Medical Corps focuses on the important role they play in addressing mental health issues. The organization educates them on mental health issues and their effect physical health. International Medical Corps developed the mental health training program for PHC providers in order to educate them about detecting, diagnosing, and treating mild-to-moderate cases. GPs were recruited from International Medical Corps-supported clinics and originated from all regions of Lebanon, with the majority from the Beirut Southern Suburbs. The clinics and centers where International Medical Corps-trained GPs work provide health-related services to both Iraqi refugees residing in those areas, as well as individuals from the host population.

Since 2008, International Medical Corps has implemented four rounds of trainings consisting of 12 days of theoretical training, followed by a minimum of three on-the-job (OTJ) supervised clinic sessions. The theoretical training days consisted of presentations regarding the most common mental health disorders that are seen by GPs, including: depression, psychosomatic disorders (also known as somatoform disorders), substance and alcohol abuse, and anxiety. The trainings were facilitated by mental health specialists and the training material reviewed by the Lebanese Psychiatric Society and approved by the Order of Physicians. In the third round of training, GPs were awarded Continuing Medical Education (CME) credits for participating. International Medical Corps, in compliance with the InterAgency Standing Committee (IASC) guidelines, believes that no theoretical training is complete without OTJ supervision. The OTJ required the participants to be supervised by a psychiatrist in order to assess whether the skills of communicating, building rapport with patients, proper diagnosing, treatment, and referral were being understood and implemented.

In the first three rounds of training 79 GPs were trained. In the fourth round, 35 additional mid-level staff members, including nurses and social workers identified by the GPs, were trained. International Medical Corps promoted a unified system of care within each clinic and center by stressing the importance of referring both downward and upward. Mid-level staff were trained on detecting symptoms of mental health disorders and how to direct referrals. In addition, communication, building rapport, and the importance of psychosocial interventions and plans were stressed. Staff learned that the patient ideally should first be seen by either a nurse or social worker, then referred to a trained GP in mental health. If the case was diagnosed as severe or out of the realm of the GP’s training and qualifications, a mental health specialist should be consulted. However, all three must work together through collaboration and constant communication in order to ensure the patient’s wellbeing and recovery.

International Medical Corps also began refresher trainings (RTs) for previously trained participants. RTs were based on previous formative evaluations on training gaps and tailored to PHC staff specializations. RTs focused on the review of major disorders, as well as psychosocial interventions and additional means of detecting mental illnesses. During RTs previously trained PHC providers were segregated into their specialties including: GPs, gynecologists, pediatricians and mid-level staff (nurses and social workers).

In November 2010, mid-level staff had two days of RTs centered on using psychosocial interventions with patients suffering from mental disorders. In addition, GPs had a three-day refresher training in February 2011 where they were educated on psychosocial interventions that focus on not overprescribing psychotropic medications. Gynecologists and pediatricians will have their refresher trainings in April 2011. Gynecologists will receive training on detecting, managing, and referring cases of abuse. Pediatricians will receive in-depth sessions on child and adolescent mental health and signs of abuse and neglect that might be casual factors in children displaying somatic complaints that have no biological causes.

International Medical Corps’ program serves as one example of designing a mental health/PHC integration curriculum and training involving formative research, constant program modifications, and close collaboration with the government and key stakeholders. As this project continues to evolve, the organization will focus on providing continued RTs, strengthening referral systems, and supporting the integration of mental health at the PHC organizational level, with the goal of contributing to and informing national mental health practice and policy.

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